,transcriber's ,note4    ,italic text is
 indicated with underscores1 bold text  
with equals4  ,small_/mixed capitals    
have been replaced with ,,all           
,,capitals4    ,obvious typographical   
and punctuation errors have been        
corrected  silently4 ,inconsistent      
hyphenation has been normalised4        
,half-titles  reiterations of the       
chapter title have been discarded4      
,,euthanasia3                           
,,or1                                   
,,medical ,,treatment ,,in ,,aid        
,,of ,,an ,,easy ,,death4               
,,by                          ,,william 
,,munk1 ,m4,d41 ,f4,s4,a4               
,,fellow ,,and ,,late ,,senior ,,censor 
,,of ,,the ,,royal ,,college ,,of       
,,physicians1 c41 c41 c4                
,,london3                               
,,longmans1 ,,green1 ,,and ,,co4        
,,and ,,new ,,york3 #ae1 ,,east #afth   
,,street4                               
#ahhg4                          ,all    
rights reserved4          ,,preface4    

,much has been ably written on ,death1  
and on the physiology of the  various   
modes of ,dying1 by ,bichat1 ,alison1   
,wilson ,philip1 ,symonds1 and  others2 
while but little has been written on the
 medical management  of the ,dying2 or  
on the ,euthanasia1 to which such       
management should  contribute4 ,a short 
but valuable essay of less than twenty  
pages1  8,on the ,treatment of the      
,dying01 by ,dr4 ,ferriar1 of           
,manchester1  in #agih3 and a very      
elegant academical oration1 of about the
 same  length1 at my own alma mater1    
,leyden1 in #agid1 by ,professor        
,paradys1  8,oratio de  ,naturali2 et   
quid ad eam conciliandam ,medicina      
valeat03--comprise all ,i know that has 
been written specially on  these        
subjects in modern times4    ,sir ,henry
 ,halford1 who was confessedly a master 
in all that concerns  the management of 
the ,dying1 did much by his example and 
counsel to  commend the subject to the  
attention of his medical brethren4 ,but 

the generation he personally influenced 
has passed away4 ,his little  volume of 
8,essays and ,orations0 contains much on
 this subject that  is very valuable1   
and not to be found elsewhere4 ,but his 
remarks are  unconnected2 they occur    
incidentally in the course of his       
various  essays1 and are now but little 
known4 ,they were the result of an      
experience so large1 and so carefully   
thought out1 that ,i have been  glad to 
adduce them1 whenever ,i could1 in      
support of1 or in addition  to1 what ,i 
have had myself to state1 on the        
delicate and difficult  subjects        
considered in the following pages4      
#dj1 ,,finsbury ,,square4    ,sept4 #bd1
 #ahhg4          ,,contents4            
,i4      ,,on ,,some ,,of ,,the         
,,phenomena ,,of ,,dying           #a   
,,ii4      ,,on ,,the ,,symptoms ,,and  
,,modes ,,of ,,dying         #ea        
,,iii4      ,,on ,,the ,,general ,,and  
,,medical ,,management         ,,of     
,,the ,,dying                           

#fc          ,i4    ,,some ,,of ,,the   
,,phenomena ,,of ,,dying4       8,quod  
ad nos ,pertinet1 et nescire malum est1 
agitamus40      ,,horace4       ,one of 
the wisest of our countrymen1 ,lord     
,verulam1 saw reason to   censure the   
physicians of his own time for not      
making the ,euthanasia a   part of their
 studies4#a ,and1 although more than two
 centuries have   since elapsed1 it may 
be doubted whether as much attention is 
even   yet given to the subject as might
 be done1 to the obvious benefit and    
comfort of the dying4     ,there is     
little to be found in medical writings  
on the management   of the dying1 or on 
the treatment best adapted to the relief
 of the   sufferings incident to that   
condition4 ,the subject is not specially
   taught in any of our medical schools2
 and the young physician entering   on  
the active duties of his office has to  
learn for himself1 as   best he may1    
what to do1 and what not to do1 in the  
most solemn and   delicate position in  

which he can be placed1--in attendance  
on the   dying1 and administering the   
resources of the medical art1 in aid    
of an easy1 gentle1 and placid death4   
,the whole subject of the               
,euthanasia1#b or of a calm and easy    
death1 in so far as it respects   the   
physician is in need of special study2  
and of a systematic   treatment that has
 not hitherto been accorded to it4#c ,in
 the   following pages ,i can but trace 
the outlines of this subject1 leaving   
to abler hands that fuller treatment    
which its interest and importance       
claim for it4     ,lord ,verulam held it
 to be as much the duty of the physician
 to smooth   the bed of death1 and      
render the departure from this life easy
 and   gentle1 as it is to cure diseases
 and restore health4#d ,and this        
doctrine1 so accordant with the best    
principles of our nature1#e   is        
commended to us by that most estimable  
and judicious of modern   physicians1   
,dr4 ,heberden2#f as it was also by the 

example and   counsel of one of the most
 popular and successful physicians of   
the   present century--the late ,sir    
,henry ,halford4#g     ,the process by  
which death is brought about varies     
greatly in   different instances1 and   
this according to the disease1 or the   
organ   of the body1 from which it      
essentially results4 ,on these diverse  
modes   of dying1 and of death1 modern  
science has thrown much light2 and      
with the consolatory result of showing  
that the process of dying1 and   the    
very act of death1 is but rarely and    
exceptionally attended by   those severe
 bodily sufferings1 which in popular    
belief are all but   inseparable from   
it1 and are expressed and emphasized in 
the terms   8mortal agony0 and 8death   
struggle40     ,montaigne was one of the
 first among modern writers to oppose1  
by   close argument1 the general opinion
 of the painfulness of death2 and   he  
was followed in the last century with   
more eloquence1 if with   less argument1

 by ,buffon4#h 8,there is hardly any    
subject10 writes   an amiable physician1
 8on which books afford us more         
impressive   topics1 than the           
consideration of death2 and perhaps     
there is none   less studied in its     
intimate details4444 ,it might be       
expected that a   scene through which we
 must all pass should excite a closer   
attention   especially as the physical  
process of death loses much of its      
horror   on a near view40#i             
,physicians1 the clergy1 and intelligent
 nurses--all1 indeed1 who   are         
practically conversant with the         
dying--testify to the truth of   this   
statement4 ,sir ,henry ,halford1 towards
 the close of his medical   career1 and 
after opportunities of observation1 such
 as have fallen   to the lot of few     
physicians1 expressed his surprise that 
of the   great number to whom it had    
been his professional duty to have      
administered in the last hours of their 
lives1 so few exhibited signs   of      

severe suffering4 ,sir ,benjamin        
,brodie1 whose experience of death      
from surgical disease was second to     
none1 states that1 according to   his   
observation1 the mere act of dying is   
seldom1 in any sense of the   word1 a   
very painful process4#aj ,and another   
distinguished surgeon1   ,mr4 ,savory1  
writing on the same subject1 says1      
8,whatever may have been   the amount of
 previous suffering1 we may fairly      
assume that1 except   in extreme cases1 
the actual process of dying is not one  
of intense   agony1 or indeed1 for the  
most part1 even of pain40#aa ,lastly1   
the   great anatomist1 ,dr4 ,william    
,hunter1 bore his own dying testimony   
to the same effect4 ,he retained his    
consciousness to the last1 and   just   
before he died he whispered to his      
friend1 ,dr4 ,combe1 8,if ,i had        
strength enough to hold a pen1 ,i would 
write how easy and pleasant a   thing it
 is to die40#ab     ,but of far greater 
weight than the observations and        

conclusions of   medical men1 however   
eminent1 towards the determination of   
such a   question1 is the evidence of   
those who have been restored from the   
state of apparent death from drowning--a
 state which differs only from   actual 
death in the possibility of reanimation 
under the influence of   external       
treatment4 ,and although the accounts   
given after recovery   from drowning    
vary much1 there are a number of        
well-attested cases   which show1 that  
in them at any rate1 the loss of        
sensibility and   consciousness has been
 painless1 or at most attended with a   
feeling   of oppression across the      
chest4 ,the process of recovery1        
however1 is   often one of great bodily 
suffering4     ,lastly1 there are those 
specially interesting cases of recovery 
from   the apparent death of drowning1  
in which1 although the mind has been    
keenly alive and active throughout1     
there was an entire absence of   pain or
 other bodily suffering of any kind4    

,the best authenticated   of these      
instructive and suggestive instances is 
that of ,admiral   ,beaufort1 as        
described by himself in a letter to ,dr4
 ,wollaston4#ac   ,when a youngster on  
board one of ,h4,m4 ships in ,portsmouth
 harbour1 he   fell into the water1 and1
 being unable to swim1 was soon         
exhausted   by his struggles1 and before
 relief reached him1 he had sunk below  
the surface4 ,all hope had fled1 all    
exertion ceased1 and he felt that   he  
was drowning4 8,from the moment that all
 exertion had ceased10   writes the     
admiral1 8a calm feeling of the most    
perfect tranquillity   superseded the   
previous tumultuous sensations--it might
 be called   apathy1 certainly not      
resignation1 for drowning no longer     
appeared   to be an evil4 ,i no longer  
thought of being rescued1 nor was ,i in 
any bodily pain4 ,on the contrary1 my   
sensations were now of rather   a       
pleasurable cast1 partaking of that     
dull1 but contented sort of   feeling   

which precedes the sleep produced by    
fatigue4 ,though the   senses were thus 
deadened1 not so the mind2 its activity 
seemed to   be invigorated in a ratio   
which defies all description--for       
thought   rose after thought with a     
rapidity of succession1 that is not only
   indescribable1 but probably          
inconceivable1 by any one who has not   
himself been in a similar situation4    
,the course of these thoughts ,i   can  
even now in a great measure             
retrace1--the event which had just      
taken place1 the awkwardness that had   
produced it1 the bustle it must   have  
occasioned1 the effect it would have on 
a most affectionate   father1 and a     
thousand other circumstances minutely   
associated with   home were the first   
series of reflections that occurred4    
,they then   took a wider range--our    
last cruise1 a former voyage and        
shipwreck1   my school1 the progress ,i 
had made there and the time ,i had      
misspent1   and even all my boyish      

pursuits and adventures4 ,thus          
travelling   backwards1 every past      
incident of my life seemed to glance    
across my   recollection in retrograde  
succession2 not1 however1 in mere       
outline   as here stated1 but the       
picture filled up with every minute and 
collateral feature2 in short1 the whole 
period of my existence seemed   to be   
placed before me in a kind of panoramic 
review1 and each act   of it seemed to  
be accompanied by a consciousness of    
right or wrong1   or by some reflection 
on its cause or its consequences2       
indeed1 many   trifling events which had
 been long forgotten1 then crowded into 
my   imagination1 and with the character
 of recent familiarity40 ,certainly     
two minutes did not elapse from the     
moment of suffocation to that of   being
 hauled up2 and according to the account
 of the lookers on1 he   was very       
quickly restored to animation4 8,my     
feelings10 continues   ,admiral         
,beaufort1 8while life was returning1   

were the very reverse in   every point  
of those which have been described      
above4 ,one single but   confused       
idea--a miserable belief that ,i was    
drowning dwelt upon my   mind1 instead  
of the multitude of clear and definite  
ideas which had   recently rushed       
through it--a helpless anxiety--a kind  
of continuous   nightmare seemed to     
press heavily on every sense1 and to    
prevent the   formation of any one      
distinct thought1 and it was with       
difficulty that   ,i became convinced   
that ,i was really alive4 ,again1       
instead of being   absolutely free from 
all bodily pain1 as in my drowning      
state1 ,i was   now tortured by pain all
 over me40     ,i have given this case  
at some length1 because it seems to     
throw a   new light on the act of dying1
 and because analogous instances are    
probably not uncommon4 ,admiral         
,beaufort tells us that he had heard    
from two or three persons1 who had      
recovered from a similar state1   a     

detail of their feelings1 which         
resembled his own as nearly as was      
consistent with their different         
constitutions and dispositions4 ,sir    
,benjamin ,brodie mentions an instance  
in a sailor2#ad ,de ,quincey   records a
 like instance in a female1 a near      
relative of his own2#ae   and ,i have   
myself heard of two similar cases1 but  
the details are not   sufficiently      
precise to justify their narration here4
     ,in fact1 all the best and all the 
most direct evidence that the   subject 
admits of1 goes to show1 that as a rule1
 the immediate act of   dying is in no  
sense a process of severe bodily        
suffering--or1 indeed1   for the most   
part even of pain4     ,the common      
belief that the act of dying is one of  
severe bodily   suffering is due        
probably in part to theoretical views of
 the nature   of the event itself2#af   
but1 principally1 to the occurrence of  
conditions1 physiological or            
pathological1 which precede or accompany

   that act1 and the nature and import  
of which are misinterpreted4            
,doubtless also1 it is due in no small  
degree to confounding the   actual stage
 of dying1 with those urgent symptoms of
 disease that   precede and lead up to  
it1 and which are often as severe or    
more so in   those who are to recover1  
as in those who are to die4 ,as a rule1 
to   which there are doubtless          
exceptions1 the urgent symptoms of      
disease   subside1 when the act of dying
 really begins4 8,a pause in nature1    
as it were1 seems to take place1 the    
disease has done its worst1   all strong
 action has ceased1 the frame is        
fatigued by its efforts   to sustain    
itself1 and a general tranquillity      
pervades the whole   system40#ag        
,again1 convulsions1 which so often     
attend the process of dying1 are        
accepted in evidence of suffering1 when 
in fact they are the reverse1   for they
 imply a loss of consciousness and      
sensibility1 and therefore1   of the    

capacity to feel pain4 ,they are        
automatic1 and in all essential         
respects like the convulsions of        
epilepsy1 of which the subject is       
wholly unconscious4 ,the convulsive     
movements that sometimes attend   the   
last moments1 and with which the person 
expires1 constituting   the so-called   
8death struggle10 are doubtless of the  
same painless   character4     ,some    
few1 however1 do really suffer          
grievously in dying1 and expire   in    
great bodily torture4 ,this occurs in   
some diseases of the heart   and great  
vessels of the chest1 in angina         
pectoris1 and in ileus4 ,but            
especially in that most fearful of      
diseases1 hydrophobia1 in tetanus1   and
 in spasmodic cholera--in maladies      
characterized by spasm of the   external
 muscles1 as distinguished from their   
convulsion1 for spasm   implies no such 
unconsciousness as does convulsion1 but 
the reverse4   ,such cases are rare1 but
 they are so terrible that they fix     

themselves   in the memory1 exert an    
undue influence on the judgment1 and1   
although   really exceptional in        
occurrence1 and in the sufferings they  
entail1   come to be regarded as but    
extreme instances of what is assumed to 
be   the universal and inevitable lot of
 the dying4 ,happily for mankind it   is
 not so4     ,so long as consciousness  
and intelligence continue1 and they     
often   do so to the last1 the influence
 of mind and of the emotions on the     
bodily process of dying must be kept    
steadily in view4 ,they are   well-nigh 
as potential in the dying man as they   
are in the healthy4   ,hope is as       
soothing and fear as depressing in the  
one condition as in   the other4 ,to the
 dying there is no greater solace and   
cordial than   hope--it is the most     
soothing and cheering of our feelings1  
and if1   when all hope of life and in  
the present has fled1 the dying man can 
dwell with hope and confidence upon his 
future1 it will be well for   him4 ,the 

retrospect of a well-spent life1        
8memoria bene act vit1   multorumque    
benefactorum recordatio0 is a cordial of
 infinitely more   efficacy than all the
 resources of the medical art2#ah but a 
firm   belief in the mercy of ,god1 and 
in the promises of salvation will do    
more than anything in aid of an easy1   
calm1 and collected death4 ,to   those  
who are sceptical on this point1 and    
such there are1 ,i would   remark1 that 
unless a man has himself felt the       
influence of religion   on his own mind1
 he is unable fully and accurately to   
understand its   influence on others4   
,if ,i may trust my own experience ,i   
should say1   that in the aggressive    
disbeliever1 as in the mere passive     
agnostic1   doubt and anxiety as to his 
future is all but sure to obtrude itself
   on his last conscious moments1       
disturb them1 and render such an        
euthanasia as we contemplate1           
impossible4     8,the less fear a       
reasonable man entertains of death10    

says ,zimmerman1   8the more placid is  
he in his last moments40 ,happily such  
dread or   terror of death as disturbs  
the dying is rare4 ,for the most part an
   urgent fear of death1 when it does   
exist1 is observed not so much   at the 
moment when death is actually impending1
 as it is at that   earlier period when 
the individual realizes for the first   
time that   he is about to die4 ,the    
shock at that moment may be great1 but  
it   is for the most part transient1 and
 8the subsequent contemplation of       
approaching death seems to be far less  
terrible40#ai ,a torpor seems   indeed  
to steal softly over the whole being as 
death approaches1   and the earnestness 
to live abates1 as the possession of    
life1 from   whatever cause1 is         
gradually withdrawn4 ,sir ,henry        
,halford tells us   that of the great   
number to whom he had administered in   
the last   hours of their lives1 he had 
felt surprised that so few have appeared
   reluctant to go to 8the undiscovered 

country from whose bourn no   traveller 
returns40#bj     ,no one1 writes ,mr4   
,savory1 who has often stood at the     
bedside of the   dying1 8can have failed
 to be struck by the fact of the        
comparative   or complete absence of    
dismay as death draws near4 ,often1 no  
doubt1   the mind is otherwise too fully
 occupied1 444 but even in the absence  
of this and all distracting influences1 
and with a clear conviction   that the  
approaching change is near at hand1--the
 mind is calm and   collected1 the      
thoughts serene1 there is no quailing1  
no giving   way40#ba     ,the nature of 
the disease under which a person        
succumbs1 would seem   to exert some    
influence in this respect4 ,sir         
,benjamin ,brodie says1   8,i have      
myself never known but two instances1 in
 which1 in the act   of dying there were
 manifest indications of the fear of    
death4   ,the individuals to whom ,i    
allude were unexpectedly destroyed by   
hemorrhage1 which from peculiar         

circumstances1 it was impossible to     
suppress4 ,the depressing effects which 
the gradual loss of blood   produced on 
their corporeal system seemed to        
influence their minds1   and they died  
earnestly imploring the relief which art
 was unable to   afford40#bb     ,when  
the intimation that death is at hand has
 been postponed to the   latest possible
 moment1 it comes upon the sufferer so  
late1 that there   may not be time for  
him to get over the shock of the first  
impression1   and regain his serenity4  
,alarm associates itself with the act of
   dissolution1 which is imminent1 or   
has already commenced1 disturbs its     
even1 easy1 tenor1 and explains some at 
least of the harrowing scenes   that    
occasionally mark the death-bed4 ,an    
earlier intimation#bc to the   dying    
person of the great change he is about  
to undergo is in all   respects         
desirable1 and if the communication be  
made tenderly and with   prudence1      
nothing but good is likely to result    

from it4 ,an important   question here  
presents itself4 ,by whom should that   
communication be   made8     8,you will 
forgive me10 said ,sir ,henry ,halford  
at one of the evening   meetings at the 
,college of ,physicians1 8if ,i presume 
to state what   appears to me to be the 
conduct proper to be observed by a      
physician   in withholding1 or making   
his patient acquainted with1 his opinion
   of the probable issue of a malady    
manifesting mortal symptoms4 ,i own   ,i
 think it my first duty to protract his 
life by all practicable   means1 and to 
interpose myself between him and        
everything which may   possibly         
aggravate his danger4 ,and unless ,i    
shall have found him   averse from doing
 what was necessary in aid of my        
remedies1 from a   want of a proper     
sense of his perilous situation1 ,i     
forbear to step   out of the bounds of  
my province in order to offer any advice
 which   is not necessary to promote his
 cure4 ,at the same time1 ,i think it   

indispensable to let his friends know   
the danger of his case the   instant ,i 
discover it4 ,an arrangement of his     
worldly affairs1 in which   the comfort 
or unhappiness of those who are to come 
after him is   involved1 may be         
necessary2 and a suggestion of his      
danger by which   the accomplishment of 
this object is to be obtained1 naturally
 induces   a contemplation of his more  
important spiritual concerns1 a careful 
review of his past life1 and such       
sincere sorrow and contrition for   what
 he has done amiss1 as justifies our    
humble hope of his pardon   and         
acceptance hereafter4 ,if friends can do
 their good offices at a   proper time1 
and under the suggestions of the        
physician1 it is far   better that they 
should undertake them than the medical  
adviser4 ,they   do so without          
destroying his hopes1 for the patient   
will still believe   that he has an     
appeal to his physician1 beyond their   
fears2 whereas1   if the physician lay  

open his danger to him1 however         
delicately he   may do this1 he runs a  
risk of appearing to pronounce a        
sentence   of condemnation to death1    
against which there is no appeal1 no    
hope4444 ,but friends may be absent1 and
 nobody near the patient in   his       
extremity1 of sufficient influence or   
pretension to inform him of   his       
dangerous condition4 ,and surely it is  
lamentable to think that   any human    
being should leave the world unprepared 
to meet his ,creator   and ,judge1      
#8with all his crimes broad blown4'     
,rather than so1 ,i have   departed from
 my strict professional duty1 and have  
done that which ,i   would have done by 
myself1 and have apprized my patient of 
the great   change he was about to      
undergo40     8,in short1 no rule1 not  
to be infringed sometimes1 can be laid  
down   on this subject4 ,every case     
requires its own considerations2 but you
   may be assured1 that if good sense   
and good feeling be not wanting1   no   

difficulty can occur which you will not 
be able to surmount with   satisfaction 
to your patient1 his friends1 and       
yourselves40#bd     ,in some instances  
the patient himself is the first to     
discover1 and   this from his own       
internal feelings1 that he is about to  
die1 and he   announces the fact calmly1
 and for the most part without alarm1 to
   those about him4     ,although a fear
 of death in itself1 or for one's own   
sake1 is rare   and exceptional1 the    
last moments of too many are made       
miserable by   solicitude for those they
 will leave behind1 and their end is    
often   one of great mental anguish4    
8,such have clung to life anxiously1    
painfully1 but they were not influenced 
so much by a love of life for   its own 
sake1 as by the distressing prospect of 
leaving children1   dependent upon them1
 to the mercy of the world1 deprived of 
their   parental care40#be           99 
99       99       99       99     ,in   
some dying persons consciousness and the

 intellect remain perfect   to the last4
 ,the cases in which this is observed   
will be found to   agree in the fact    
that the brain is correspondently       
unimpaired2 they   are for the most part
 chronic diseases of the chest and      
abdomen4 ,if   the character of the     
dying person is naturally strong1 the   
state of   his mind at the approach of  
death will generally be influenced by   
it4   ,of those who retain consciousness
 and intellect1 the majority die        
thinking and acting in accordance with  
the influences that have been   exerted 
upon them in previous life1 by education
 and example3 and with   those which may
 be then brought to bear upon them1     
towards and at its   close4     ,more   
often some delirium is present4 ,the    
delirium of the dying is   often of a   
most interesting character1 and         
according to ,dr4 ,symonds   resembles  
dreaming more than any form of          
derangement4 ,the ideas are   derived   
less from present perceptions than in   

insanity1 and yet are   more suggested  
by external circumstances than in the   
delirium of   fever and phrenitis4#bf   
,such delirium is generally shown in    
quiet   talkativeness1 which becomes    
later on a low muttering4 ,in some the  
mind is occupied on the events of       
childhood and early life1 but   when the
 delirium is somewhat more active1 the  
conceptions of the   dying man are      
generally derived from subjects1 which1 
either in his   speculative pursuits or 
in the business of life1 have           
principally   occupied his thoughts4#bg 
,lord ,tenterden1 as he approached his  
end1   became delirious and talked very 
incoherently4 ,afterwards he seemed to  
recover his composure1 and raising his  
head from his pillow1 he was   heard to 
say in a slow and solemn tone1 as when  
he used to conclude   his summing up1 in
 cases of great importance1 8,and1 now1 
,gentlemen   of the ,jury1 you will     
consider of your verdict40 ,these were  
his last   words2 when he had uttered   

them1 his head sunk down1 and in a few  
minutes he expired without a groan4#bh  
,and the last words of ,dr4   ,armstrong
 were addressed to an imaginary patient1
 upon whom he was   impressing the      
necessity of attention to the state of  
the digestive   organs4     ,instances  
occur1 and not very rarely1 where the   
delirium ceases1 and   the mind again   
for a time becomes clear and the        
sensations keen1 to   be followed1      
however1 ere long by a return of        
delirium1 or it may   be of coma1 or a  
rapid sinking of all the bodily powers  
and speedy   death4 ,but along with this
 temporary clearing of the mental       
powers1   and in proof of its           
illusiveness1 there are the usual signs 
of bodily   failure--a pinching of the  
features1 coldness of the surface1 cold 
sweats1 and a feeble rapid pulse4       
,active delirium and violence are but   
rarely associated with the act   of     
dying1--they are indeed scarcely        
compatible with it4 ,they may pave   the

 way to it1 but when the act of dying   
really begins1 they cease and   give way
 to that low1 rambling1 muttering       
delirium1 with which all   watchers by  
the death-bed are so familiar4     ,it  
is especially at the stage of transition
 from the one to the other   of these   
states1 that we meet with that return of
 intelligence--that   #8lightening up   
before death' which has impressed and   
surprised mankind   from the earliest   
ages4 8,we have all observed10 writes   
,sir ,henry   ,halford1 8the mind clear 
up in an extraordinary manner in the    
last   hours of life1 when terminated   
even in the ordinary course of nature2  
but certainly still more remarkably when
 it has been cut short by   disease1    
which had affected1 for a time the      
intellectual faculties4 ,we   have seen 
it become capable of exercising a subtle
 judgment1 when the   passions which had
 been accustomed to bias and embarrass  
its decisions   whilst they existed1 are
 extinguished at the approach of death2 

and   when the inferences which wisdom  
had drawn from experience of the        
former behaviour of men1 were now made  
available to a correct estimate   of    
their future conduct1 in the sense of   
,milton's lines--0        #8,when old   
experience does attain      ,to         
something like prophetic strain4'#bi    
8,this is most frequently the case when 
the resistance of the   constitution    
against the influence of the disease has
 been long   protracted1 or when the    
struggle1 though short1 has been very   
violent40#cj     8,a young gentleman of 
family1 about twenty-five years of age1 
took   cold whilst under the influence  
of mercury4 ,the disease increased      
daily until it was accompanied at last1 
by so much fever and delirium1   as made
 it necessary to use1 not only the most 
powerful medicines1   but also personal 
restraint4 ,at length1 after three days 
of incessant   exertion1 during which he
 never slept for an instant1 he ceased  
to   rave1 and was calm and collected4  

,his perception of external objects     
became correct1 and they no longer      
distressed him1 and he asked            
pressingly if it were possible that he  
could live8 ,on being answered          
tenderly1 but not in a way calculated to
 deceive1 that it was probable   he     
might not1 he dictated some affectionate
 communications to his   friends abroad1
 recollected some claims upon his purse1
 #8set his   house in order1' and died  
the following night4 ,the reason why so 
unfavourable an opinion was entertained 
of his state1 was1 that the   apparent  
amendment was not preceded by sleep1 and
 was not accompanied   by a slower      
pulse2 two indispensable conditions--on 
which only a   notion of real           
improvement could be justified4 ,but    
here was merely   a cessation of        
excitement occasioned by a diminution of
 power1 and   by a mitigated influence  
of the action of the heart upon the     
brain40   ,this case occurred in the    
practice of ,sir ,henry ,halford4#ca    

,another   instance1 the counterpart to 
that just described1 which happened to  
the same eminent physician1 may not be  
out of place4     ,a young gentlemen1   
who had also been using mercury very    
largely1   caught cold1 and became      
seriously ill with fever4 8,his head    
appeared   to be affected on the fifth  
day1 and on the seventh1 when ,i was    
first   called into consultation with   
another physician1 who had attended him 
with great care and judgment from the   
commencement of his illness1 we   found 
him in the highest possible state of    
excitement4 ,he was stark   naked1      
standing upright in bed1 his eyes       
flashing fire1 exquisitely   alive to   
every movement about him1 and so        
irascible as not to be   approached     
without increasing his irritation to a  
degree of fury4444   ,on the eleventh   
day of his disease1 ,i was informed by  
my colleague1   when we met1 and by the 
attendants1 that he was become quite    
calm1   and seemed much better4 ,it was 

remarked1 indeed1 that he had said      
repeatedly1 that he should die2 that    
under this conviction he had   talked   
with great composure of his affairs2    
that he had mentioned   several debts   
which he had contracted1 and made       
provision for their   payment1--that he 
had dictated messages to his mother1    
expressive of   his affection1 and had  
talked much of a sister who had died the
 year   before1 and whom1 he said1 he   
knew he was about to follow immediately4
   ,to my questions1 whether he had     
slept previously to this state of       
quietude1 and whether his pulse had come
 down1 it was answered1 ,no2   he had   
not slept1 and his pulse was quicker    
than ever4 ,then it was   evident that  
this specious improvement was unreal1   
that the clearing   up of his mind was a
 mortal sign1 #8a lightening before     
death1' and   that he would die         
forthwith4 ,on entering his room he did 
not   notice us2 his eyes were fixed on 
vacancy1 he was occupied entirely       

within himself1 and all that we could   
gather from his words was some          
indistinct mention of his sister4 ,his  
hands were cold1 and his pulse          
immeasurably quick--he died that        
night40#cb     ,some pass away in sleep4
 ,in natural healthy sleep respiration  
becomes   slower1 the pulse weaker and  
less frequent1 the circulation generally
   feebler4 ,the difference in these    
respects between the waking and the     
sleeping states1 is to the dying person 
often the difference between   life1 and
 death4 ,the circulation already reduced
 to the lowest ebb   compatible with    
life1 is yet further reduced by sleep1  
and with this   reduction the patient   
dies4 ,these are those who #8sleep      
away4' ,similar   to1 if not identical  
with them1 are those to whom death comes
 so   easily that not a ruffle disturbs 
any portion of the frame1 and the   most
 intelligent observer is unable to fix  
the moment when life has   fled1 so easy
 is the parting of the last link1 #8when

 the body drops   to earth and the soul 
rises to eternity4' ,it is probable that
 here1 a   mere act of dozing becomes   
the act of dying4 ,in these instances as
 in   old age1 death is literally the   
last sleep1 uncharacterized by any      
peculiarity4 ,the general languor of the
 functions in the last waking           
interval1 is attended with no peculiar  
suffering1 and the last sleep           
commences with the usual grateful       
feelings of repose4#cc     ,the length  
of the interval between insensibility   
and the absolute   cessation of         
existence1 varies greatly from a few    
seconds to several   hours or days4 ,but
 consciousness is often retained much   
longer than   is generally supposed1 and
 it is difficult to determine when the  
external senses1 and particularly that  
of hearing1 are completely and          
absolutely closed4     ,the senses of   
smell1 taste1 and touch are generally   
the first to   fail us and disappear1   
while those of sight and hearing        

continue much   longer4     ,abnormal   
visual impressions are common when death
 is near at hand4 ,in   many the sight  
fails1--there is complaint of commencing
 or of actual   darkness1 and a desire  
is expressed for more light2 while more 
rarely1   the dying one perceives a     
blaze of light1 in the contemplation of 
which1 or immediately afterwards1 he    
calmly expires4 8,it happens not        
unfrequently10 writes ,dr4 ,symonds in  
his admirable essay on ,death1#cd       
8that the spectra of the dying owe their
 origin to contemplations   of future   
existence1 and consequently that the    
good man's last   hours are cheered with
 beatific visions and communion with    
heavenly   visitors4 ,dreadfully        
contrasted with such visions are those  
which   haunt the dying fancies of      
others40#ce ,the testimony of many of   
those who have the largest experience1  
and have watched continuously   and     
attentively at the dying bed1 is in     
support of ,dr4 ,symonds'   statement4  

,if some physicians are incredulous1 and
 place little   reliance on testimony   
and inferences of this kind1 ,i am      
inclined with   ,dr4 ,conolly#cf to     
attribute it1 to their being seldom     
engaged long   enough in watching by the
 bedside1 where the senses and thoughts 
naturally become concentrated on the    
events of the sick chamber   alone4 ,my 
own observation in cases1 where         
circumstances have made my   attendance 
on the dying close and protracted1 goes 
to corroborate the   evidence there is  
on these points--points which are       
certainly not of   a nature to be made  
familiar to those1 whose chief knowledge
 of the   dying is acquired in formal   
consultations1 or in short daily visits 
to   the wards of hospitals4            
,hearing is1 probably in most cases1 the
 last of our senses to leave   us4 8,an 
elderly lady had a stroke of apoplexy2  
she lay motionless1 and   in what is    
called a state of stupor1 and no one    
doubted that she was   dying4 ,but after

 the lapse of three or four days1 there 
were signs   of amendment1 and she      
ultimately recovered4 ,after her        
recovery she   explained that she did   
not believe that she had been           
unconscious1   or even insensible1      
during any part of the attack4 ,she knew
 her   situation1 and heard much of what
 was said by those around her4          
,especially she recollected observations
 intimating that she would very   soon  
be no more1 but that at the same time   
she had felt satisfied that   she would 
recover2 that she had no power of       
expressing what she felt1   but that    
nevertheless her feelings1 instead of   
being painful or in   any way           
distressing1 had been agreeable rather  
than otherwise4 ,she   described them as
 very peculiar--as if she were          
constantly mounting   upwards1 and as   
something very different from what she  
had ever before   experienced40#cg      
,the case of ,dr4 ,wollaston the        
physician and chemical philosopher is to

   the same effect4 8,some time before  
his life was finally extinguished   he  
was seen to be pale1 as if there was    
scarcely any circulation   of blood     
going on--motionless1 and to all        
appearance in a state of   complete     
insensibility4 ,being in this condition1
 his friends who were   watching round  
him1 observed some motions of the hand  
which was not   affected by the         
paralysis4 ,after some time it occurred 
to them1 that   he wished to have a     
pencil and paper1 and these having been 
supplied1   he contrived to write some  
figures in arithmetical progression1    
which   however imperfectly scrawled1   
were yet sufficiently legible4 ,it was  
supposed that he had overheard some     
remarks respecting the state in   which 
he was1 and that his object was to show1
 that he preserved his   sensibility and
 consciousness4 ,something like this    
occurred some hours   afterwards1 and   
immediately before he died1 but the     
scrawl of these   last moments could not

 be deciphered40#ch     8,i have been   
curious10 writes ,sir ,benjamin ,brodie 
in commenting on   these cases1 8to     
watch the state of dying persons in this
 respect1   and ,i am satisfied10 7and  
,i may add1 my own experience confirms  
,sir   ,benjamin ,brodie's statement7   
8that1 where an ordinary observer would 
not for an instant doubt that the       
individual is in a state of complete    
stupor1 the mind is often active even at
 the very moment of death4 ,a   friend  
of mine1 who had been for many years the
 excellent chaplain of   a large        
hospital1 informed me1 that his still   
larger experience had   led him to the  
same conclusion40#ci     ,instances such
 as these should teach the physician and
 all who are   about the dying1 to be   
careful neither to say1 nor do anything 
in the   presence of the patient1 which 
they would wish him not to hear4 ,their 
bearing on religious offices to the     
dying is obvious4           99       99 
99       99       99     ,sometimes1    

immediately preceding the very act of   
death1 the eyelids   are raised1 and a  
look of recognition of those around     
seems to be   permitted to the dying    
man4 ,less often there is an expression 
of agony   in the eye4 8,it is          
consolatory to know10 says ,sir ,charles
 ,bell1 8that   this does not indicate  
suffering1 but increasing insensibility4
 ,the   pupils are turned upwards and   
inwards4 ,this is especially observed   
in those who are expiring from loss of  
blood4 ,it is the strabismus            
patheticus orantium of ,boerhaave40#dj  
,the nature of the disease and the mode 
of death exert a marked   influence on  
the expression of face of the dying1 and
 this is   often retained by the        
features after death4 ,in some we       
observe the   impress of the previous   
suffering1 as in peritonitis and in     
cases   of poisoning by irritants2 in   
others the character is derived from   a
 peculiar affection of some part of the 
respiratory apparatus2 or   from an     

affection of the facial muscles         
themselves1 as in tetanus   and         
paralysis4 ,but the condition of the    
mind is perhaps more often   concerned  
in the expression than even the physical
 circumstances of   the body4 ,for1 as  
some kind of intelligence is frequently 
retained1   and strong emotions are     
experienced till within a few moments of
   dissolution1 the features may be     
sealed by the hand of death in the      
last look of rapture or of misery1 of   
benignity or of anger4 ,every   poetical
 reader knows the picture of the traits 
of death 7no less   true than beautiful7
 drawn by the author of 8,the ,giaour40 
,but such   observations are not        
confined to poets4 ,haller could trace  
in the   dying countenance the smile    
which had been lighted by the hope of   
a happier existence4 8,adfulgentis      
fugienti anim spei non raro in          
moribundis signa vidi1 qui serenissimo  
vultu non sine blando subrisu1   de vita
 excesserunt40#da       ,,footnotes3    

#a 8,at nostris temporibus1 ,medici     
quasi religio est1 grotis1 postquam     
deplorati sint1 assidere2 ubi meo       
judicio1 si officio suo1 atque  adeo    
humanitati ipsi deesse nolint1 et artem 
ediscere et diligentiam  prstare        
deberent1 qua animam agentes facilius et
 mitius e vita  demigrent--,hanc autem  
partem1 inquisitionem de ,euthanasia    
exteriori  7ad differentiam ejus        
euthanasi qu anim prparationem respicit7
  appellamus2 eamque inter desiderata   
reponimus40 7,verulamus1 ,de  ,augmentis
 ,scientiarum1 lib4 iv4 cap4 ij47     #b
 8 naturalis nobis dicitur facilis et   
quam minimo cum  cruciatu e vita exitus1
 qua tenus moriendi facilitas e causis  
naturalibus proxime pendet4444 ,ad      
medicinam hujus   contemplatio pertinet3
 est enim naturalis1 non moralis1 nisi  
qua tenus  hc ad illam momenti habet    
plurimum4 ,exteriorem idcirco           
,verulamius  appellavit40 7,nicolai     
,paradysii1 ,opuscula ,academica1 #hvo1 
,lugd4 ,batav1  #ahac4 ,oratio de       

naturali et quid ad eam conciliandam    
,medicina  valeat1 pp4 #fc et #fe47     
#c 8,a medicis vix inchoatum1 nedum     
pertractatum huc usque esset40          
7,paradysius1 p4 #fc47     #d 8,etiam   
plane censeo ad officium medici         
pertinere1 non tantum ut  sanitatem     
restituat3 verum etiam ut dolores et    
cruciatus morborum  mitiget3 neque id   
ipsum solummodo1 cum illa mitigatio     
doloris1 veluti  symptomatis periculosi1
 ad convalescentiam faciat et conducat3 
imo vero  cum abjecta prorsus omni      
sanitatis spe1 excessum tantum prbeat e 
vita  magis lenem et placidum4 ,siquidem
 non parva est felicitatis pars1 illa   
,euthanasia40 7,de ,augmentis           
,scientiarum47     #e ,sir ,henry       
,halford1 ,essays and ,orations read and
 delivered at the  ,royal ,college of   
,physicians4 ,third edition1 #abmo1     
,london1 #ahdb4 p4 #hd4     #f 8,magnus 
ille ver philosophi instaurator         
,verulamus1 queritur  studium ,euthanasi
 medicis haud satis cultum fuisse4      

,medici profecto  munus est grotis      
sanitatem reddere2 cum tamen ex lege    
natur erit  tandem unicuique mortalium  
grotatio nulla arte medicabilis1 benevol
  hujus artis professoribus conveniret1 
mortem inevitabilem1 quantum  fieri     
potest1 terrore omni spoliare2 et ubi   
non datum est prdam morti  extorquere1  
sed vita necessario amittenda est1      
operam saltem dare1  ut cum minima      
crudelitatis specie amittatur40         
7,heberdeni ,gulielmi1  ,commentaria de 
,morborum ,historia et ,curatione4 ,cap 
,de ,ileo47     #g ,essays and          
,orations1 ut supra passim4     #h ,john
 ,ferriar1 ,m4,d41 ,medical ,histories  
and ,reflections4 #hvo1 ,london1  #agih4
 ,vol4 iii4 p4 #aif4     #i ,john       
,ferriar1 ,m4,d41 ,on the ,treatment of 
the ,dying1 ut supra1 p4  #aia4     #aj 
,the ,works of ,sir ,benjamin ,collins  
,brodie4 ,arranged by ,charles          
,hawkins4 #c ,vols41 #hvo1 ,london1     
#ahfe4 ,vol4 i4 p4 #ahd4     #aa ,on    
,life and ,death4 #hvo4 ,london1 #ahfc1 

p4 #age4     #ab 8,ips anim discessus a 
corpore fit1 sine dolore1 et fit        
plerumque  sine sensu1 nonnunquam etiam 
cum voluptate40 7,vopisci ,fortunati    
,plempii4 de ,togatorum ,valetudine     
tuenda ,commentatio4 #dto4 ,bruxellis1  
#afgj4 p4 #bf47     #ac                 
,autobiographical ,memoir of ,sir ,john 
,barrow1 ,bart4 #hvo1 ,london1  #ahdg1  
p4 #cih4     #ad 8,a sailor who had been
 snatched from the waves1 after lying   
for  some time insensible on the deck of
 the vessel1 proclaimed on his  recovery
 that he had been in ,heaven1 and       
complained bitterly of his  being       
restored to life as a great hardship4   
,the man had been regarded  as a        
worthless fellow2 but from the time of  
the accident having  occurred1 his moral
 character was altered1 and he became   
one of the  best conducted sailors in   
the ship40 7,the ,works of ,sir         
,benjamin ,brodie1  vol4 i4 p4 #ahd47   
#ae ,i was once told by a near relative 
of mine--says ,de ,quincey--that  having

 in her childhood fallen into a river1  
and being on the very  verge of death   
but for the assistance which reached her
 at the  last critical moment1 she saw  
in a moment her whole life1 clothed  in 
its forgotten incidents1 arrayed before 
her as in a mirror1 not  successively1  
but simultaneously2 and she had a       
faculty developed as  suddenly for      
comprehending the whole and every part4 
,the heroine of  this remarkable case1  
continues ,de ,quincey1 was a girl about
 nine  years old2 and there can be      
little doubt that she looked down as    
far within the crater of death--that    
awful volcano--as any human  being ever 
can have done that has lived to draw    
back and to report  her experience4 ,not
 less than ninety years did she survive 
this  memorable escape1 and ,i may      
describe her as in all respects a woman 
of remarkable and interesting qualities4
 ,she enjoyed throughout her  long life 
serene and cloudless health2 had a      
masculine understanding2  reverenced    

truth not less than did the             
,evangelists2 and led a life  of saintly
 devotion1 such as might have glorified 
,hilarion or ,paul6  ,i mention these   
traits as characterising her in a       
memorable extent1  that the reader may  
not suppose himself relying upon a      
dealer in  exaggerations1 upon a        
credulous enthusiast1 or upon a careless
 wielder  of language4 ,forty-five years
 had intervened between the first time  
and the last time of her telling me this
 anecdote1 and not one iota  had shifted
 its ground amongst the incidents1 nor  
had any of the most  trivial of the     
circumstances suffered change4 ,how long
 the child lay in  the water was        
probably never inquired earnestly until 
the answer had  become irrecoverable3   
for a servant to whose care the child   
was then  confided1 had a natural       
interest in suppressing the whole case4 
,from  the child's own account it would 
seem that asphyxia must have announced  
its commencement4 ,a process of struggle

 and deadly suffocation was  passed     
through half-consciously4 ,this process 
terminated in a sudden  blow apparently 
on or in the brain1 after which there   
was no pain  or conflict3 but in an     
instant succeeded a dazzling rush of    
light2  immediately after which came the
 solemn apocalypse of the entire past   
life4 7,de ,quincey's ,works1 ,edinb41  
#ahfb1 ,vol4 ,i41 ,confessions of an    
,english ,opium-,eater1 p4 #bei47 ,sir  
,dyce ,duckworth reminds us that the    
mental condition of some who have been  
put to sleep with ansthetics  may throw 
some light on this matter4 8,patients10 
says he1 8have told  us they dreamed    
they were transported from earth and    
carried off  into space1 were supremely 
happy and at rest3 but that on gradually
  recovering consciousness1 they seemed 
to light back again upon this  world1   
were most reluctant to leave the        
,elysium they had reached1 and  to      
recommence their earthly toils and      
struggles40 7,the ,agony of ,dying1  in 

,monthly ,paper of the ,guild of ,st4   
,barnabas for ,nurses4 ,vol4 iii4 p4    
#ha74     #af ,j4 ,a4 ,symonds1 ,m4,d41 
,art4 ,death1 in the ,cyclopdia of      
,anatomy and  ,physiology1 #d vols41    
royal #hvo1 ,lond4 ,vol4 i4 p4 #hjj4    
#ag ,halford1 p4 #ah4     #ah ,halford1 
p4 #ad4     #ai ,savory1 ut supra1 p4   
#agh4     #bj p4 #gd4     #ba ,on ,life 
and ,death1 #hvo1 ,london1 #ahfc1 p4    
#agg4     #bb ,brodie ut supra1 p4 #ahe4
     #bc 8,i think there is reason for  
affirming that the risk of evil from    
this cause is rated generally above the 
truth4 ,in cases of imminent  danger1   
the mind is not always1 or even         
commonly1 to be interpreted  by the rule
 of health4 ,mental emotions are often  
altered in kind1  or greatly abated in  
degree4 ,death itself is beheld under   
different  views--a fact familiar to all
 who have watched over these scenes1 and
  regarded the patient apart from those 
who are grieving around his  death-bed4 
,suspicion of a painful truth often     

disturbs much more than  the truth      
plainly stated40 7,sir ,henry ,holland's
 ,medical ,notes and  ,reflections4     
,third edition1 #hvo4 ,lond4 #ahec1 p4  
#cfb74     #bd ,halford1 p4 #gf4     #be
 ,halford1 p4 #ge4     #bf ,cyclopdia of
 ,anatomy and ,physiology1 art4 ,death1 
vol4 i4 p4 #gii4     #bg ,symonds ut    
supra1 p4 #gii4     #bh ,lord ,campbell1
 ,lives of the ,chief ,justices of      
,england1 vol4 i4     #bi ,on the  of   
,aretus1 p4 #if4     #cj ,halford1 ,on  
the ,cautious ,estimation of ,symptoms1 
p4 #ag4     #ca ,halford ut supra1 p4   
#ai4     #cb ,on the  of ,aretus1 p4    
#ia4     #cc ,a4 ,p4 ,wilson ,philip1   
,on ,sleep and ,death1 #hvo1 ,london1   
#ahcd1 p4 #afe4     #cd ,cyclopdia of   
,anatomy and ,physiology1 vol4 i4 p4    
#gii4     #ce ,dr4 ,symonds continues1  
8,the previous habits and conduct of the
  individual have sometimes been such as
 to incline spectators to  inquire1     
whether in the mode of his departure    
from existence1 he  might not already be

 receiving retribution1 just as1 in     
other cases1  celestial dreams and      
colloquies have seemed fitting rewards  
for  blameless lives and religious      
meditation40     #cf ,cyclopdia of      
,practical ,medicine1 art4 ,disease1    
vol4 i4 p4 #fbi4     #cg ,brodie1 ut    
supra1 vol4 i4 p4 #bha4     #ch ,brodie 
ut supra1 p4 #ahb4     #ci ,brodie1 p4  
#ahb4     #dj ,the ,anatomy and         
,philosophy of ,expression4 ,fourth     
,edition1 #ahdg1 p4  #ahe4     #da      
,symonds1 ut supra1 p4 #hjc4            
,,ii4     ,,the ,,symptoms ,,and ,,modes
 ,,of ,,dying4       ,it is often       
difficult to determine when the act of  
dying really   begins4 ,practically1 it 
should be dated from the moment when the
   physician concludes from reliable    
signs1 not only that the disease   under
 which the patient labours is incurable 
by nature or art1 but   that the vital  
powers are already so utterly reduced   
that they are   beyond the possibility  
of restoration4#db ,and on these points 

the ,father of ,physic is perhaps still 
our best guide4 ,a sharp and   pinched  
nose1 the eyes sunk in the orbits and   
hollow1 the ears   pale1 cold1 shrunk1  
with their lobes inverted1 and the face 
pallid1   livid1 or black2 these        
together make up the celebrated facies  
,hippocratica1#dc and show that the work
 of dying has commenced1 and   has      
already made some progress4 ,they are   
signs of utter exhaustion   in the      
circulation and in the muscular system1 
and they point to a   loosening of all  
the bonds#dd by which being is held     
together in the   human frame4     ,to  
these may be added the glazed           
half-closed eye2 the dropped jaw and    
open mouth2 the blanched1 cold1 and     
flaccid lip2 cold clammy sweats on   the
 head and neck2 a hurried1 shallow      
respiration on the one hand1 or   slow1 
stertorous breathing with rattle in the 
throat upon the other2   a pulse        
irregular1 unequal1 weak1 and           
immeasurably frequent2 the   patient    

prostrate upon his back2 and sliding    
down towards the foot   of the bed2 his 
arms and legs extended1 naked1 and      
tossed about in   disorder2 the hands   
waved languidly before the face1 groping
 through   empty air1 fumbling with the 
sheets1 or picking at the bedclothes4   
,these latter symptoms come on for the  
most part later in the series2   they   
are the immediate precursors of death1  
and show that that event   is near at   
hand4     ,more or fewer of these       
phenomena are to be seen in most dying  
persons2 but they vary in number and    
character1 in the order of their        
appearance1 and in their combination1   
according to the nature of the   disease
 in the course of which they occur1 and 
of the mode of dying   to which they    
severally tend4 8,although10 says ,sir  
,thomas ,watson1   8all men must die1   
all do not die in the same manner4 ,in  
one instance   the thread of existence  
is suddenly snapped1 the passage from   
life   and apparent health perhaps to   

the condition of a corpse is made in   a
 moment3 in another the process of      
dissolution is slow and tedious1   and  
we scarcely know the precise instant in 
which the solemn change   is complete4  
,one man retains possession of his      
intellect up to his   latest breath2    
another lies unconscious and insensible 
to all outward   impressions for hours  
or days before the struggle is over40#de
     ,whatever may be the remote causes 
of dissolution1 the modes in which      
death is actually brought about vary    
remarkably1 according as it   begins in 
the heart1 in the lungs1 or in the      
brain4     ,death beginning at the heart
 is sometimes instantaneous4 ,suddenly  
and without warning of any kind1 the    
heart ceases to beat1 the   individual  
turns pale1 falls back or drops down and
 expires with one   gasp4 ,but oftener1 
death takes place slowly1 there is a    
more or less   lengthened period of     
exhaustion1 and death occurs in the way 
either of   syncope1 or of asthenia4    

,the phenomena which attend dying by    
syncope   are described by ,sir ,thomas 
,watson as 8paleness of the face and    
lips1   cold sweats1 dimness of vision1 
dilated pupils1 vertigo1 a slow1   weak1
 irregular pulse1 and speedy            
insensibility4 ,with these symptoms     
are frequently conjoined nausea and even
 vomiting1 restlessness and   tossing of
 the limbs1 transient delirium2 the     
breathing is irregular1   sighing1 and1 
at last1 gasping2 and convulsions       
generally occur1   and are once or twice
 repeated before the scene closes40#df  
,when   death occurs from asthenia or   
failure of contractile power in the     
heart1 8the pulse becomes very feeble   
and frequent1 and the muscular          
debility extreme1 but the senses are    
perfect1 the hearing is sometimes   even
 painfully acute1 and the intellect     
remains clear to the last40#dg          
,death beginning at the lungs1 from     
asphyxia or suffocation1 is marked   by 
laborious heaving of the chest1 strong  

but ineffectual contractions   of the   
respiratory muscles1 distress about the 
breast2 8the face   at first becomes    
flushed and turgid1 then livid and      
purplish1 the   veins of the head and   
neck swell1 and the eyes seem to        
protrude from   their sockets4 ,there is
 vertigo1 then loss of consciousness1   
and   then convulsions40#dh ,the livid  
face and laboured breathing are         
accepted as evidence of severe bodily   
suffering1 but they are only   partially
 so1 for the circulation of             
undecarbonized blood on which   they    
severally depend1 through the brain1 in 
common with other   parts of the frame1 
first benumbs sensibility1 and then     
abolishes   it altogether4 8,disturbance
 of respiration10 says ,dr4 ,ferriar1#di
   8is often the only apparent source of
 uneasiness to the dying1 but           
sensibility seems to be impaired in     
exact proportion to the decrease   of   
that function40     ,death beginning at 
the brain destroys life indirectly--by  

its   influence on the lungs or on the  
heart1 and so by the way of coma or   of
 asthenia4 ,in death by coma there is   
8stupor more or less profound2   the    
sensibility to outward impressions is   
destroyed1 sometimes   wholly and at    
once1 much oftener gradually2 the       
respiration becomes   slow1 irregular1  
stertorous2 all voluntary attention to  
the act of   breathing is lost1 but the 
instinctive motions continue4 ,at length
   the chest ceases to expand1 the blood
 is no longer arated10#ej and           
thenceforward precisely the same        
internal changes occur as in death1     
beginning at the lung4 ,it is in this   
way that most fatal disorders   of the  
brain produce death4 ,when death        
starting from the brain acts   through  
the heart1 it occurs somewhat suddenly1 
and in the way of   shock1 as in some of
 the worst cases of apoplexy--the       
8apoplexie   foudroyante10 for          
example--or more slowly1 in the way of  
exhaustion or   asthenia1 as in some    

cases of delirium tremens1 or of        
phrensy--and as   happened in the two   
cases described at pages #cf and #ch4   
,the several modes of dying described   
above1 are often combined in   the same 
person1 complicating the process and    
confusing our views of   it2 with the   
effect too1 in some cases1 of increasing
 the sufferings   of the dying1 but in  
others of lessening them4 ,thus coma1   
from   implication of the brain         
supervening on diseases of the lung1    
first   lessens the perception of the   
distress and anguish which attend       
them1 and then extinguishes it4 ,these  
mixed forms of death are seen           
especially in fevers4       ,,footnotes3
     #db 8,at ,medicus moriendi initium 
altius repetet1 et jam ab eo inde       
tempore ducet1 quo signis minime dubiis 
cognoverit1 morbum natur  artique non   
tantum insuperabilem esse1 sed et sub eo
 vires sic perire  ut reparari          
nequeant40 7,paradys1 ,oratio de        
naturali1 p4 #fg74     #dc ,in the words

 of ,lucretius1 vi4 #a1 #aij--          
8,item1 ad supremum denique tempus1     
,compress nares1 nasi primoris  acumen  
,tenue1 cavatei oculei1 cava tempora2   
frigida pellis1 ,duraque1  inhorrebat   
tactum2 frons tenta meabat3 ,nec nimio  
rigida post artus  morte jacebant40     
,or1 as rendered by an accomplished     
physician1 ,dr4 ,mason ,good--          
8,then1 tow'rds the last1 the nostrils  
close collaps'd2 ,the nose  acute2 eyes 
hollow2 temples scoop'd2 ,frigid the    
skin1 retracted2 o'er  the mouth ,a     
ghastly grin2 the shrivell'd forehead   
tense2 ,the limbs  outstretch'd for     
instant death prepar'd40     #dd 8,omnia
 tum vero vitai claustra lababant40     
7,lucretius1 vi4 #a1aea74    8,then all 
the powers of life were loosen'd40      
7,mason ,good74     #de ,lectures on the
 ,principles and ,practice of ,physic4  
,fifth edition1  #b vols4 #hvo1 ,london1
 #ahga1 vol4 i4 p4 #fb4 ,sir ,thomas    
,watson in his  admirable lecture on the
 ,different ,modes of ,dying1 has       

treated the  whole subject so           
graphically1 that ,i shall follow him as
 closely as  possible in what ,i have to
 adduce on this part of my subject4     
#df ,watson1 p4 #ff4     #dg ,watson1 p4
 #fh4     #dh ,ibid41 p4 #gj4     #di   
,on the ,treatment of the ,dying4       
,medical ,histories and ,reflections4   
,vol4 iii4 p4 #aie4     #ej ,watson1 p4 
#gf4           ,,iii4     ,,the         
,,general ,,and ,,medical ,,treatment   
,,of ,,the ,,dying4       ,many of the  
sufferings of the death-bed are not     
naturally or   necessarily incident to  
the act of the dying2 but are due to    
surrounding circumstances that admit of 
alteration or removal4 ,thus1           
restlessness and jactitation are often  
due to the weight of the bed            
coverings1 and are at once removed by   
lightening them2--difficulty   of       
breathing and gasping1 increased by the 
heat and closeness of the   chamber1 are
 removed by the admission of fresh and  
cooler air1 by   change of posture and  

by pillows carefully adapted to the     
efficient   support of the trunk of the 
body4     ,there is nothing of greater  
importance in the treatment of the dying
   than the right administration of     
nutriment4 ,errors in feeding are the   
cause of much of the disquietude and of 
many of the sufferings that   attend the
 dying4 ,the sinking and exhaustion that
 are in progress   throughout the       
system1 are assumed by the attendants to
 demand a free   administration of food 
and stimulants1 forgetting that the     
stomach   shares in the exhaustion1 and 
has lost its tone1 and in great part1 if
   not wholly1 its power of digesting4  
,food is given too frequently1 and   in 
quantities too large4 ,the dying person 
is induced by the wearisome             
importunity of his attendants to take   
food or stimulants1 against   which     
nature and his stomach revolt4 ,the     
evident dislike and loathing   with     
which he submits1 the difficulty he has 
in swallowing it1 and the   urging and  

retching which that act sometimes       
induces1 ought to save   him from what  
is really under the circumstances an act
 of cruelty4   8,here10 to use the words
 of ,sir ,henry ,holland1 8we are called
 upon to   maintain the cause of the    
patient1 for such it truly is1 against  
the   mistaken importunities which often
 surround him1 and which it requires    
much firmness in the physician to put   
aside40#ea ,the wishes of the   patient 
himself1 when he has reached the stage  
of existence here   contemplated1 may   
generally be taken as a correct         
indication in all   that relates to the 
administration of food and stimulants4  
,food when unwisely given1 accumulates  
in the stomach1 distends and            
distresses it1 and impedes the          
respiration4 ,under such circumstances  
the pit of the stomach will be found    
tumid and tense1 dull upon   percussion1
 and intolerant of pressure4 ,at length 
some of the contents   of the distended 
stomach regurgitate into the throat or  

mouth2 or   there may be actual         
vomiting1 and this to the evident relief
 of the   sufferer4 ,hiccup is often due
 solely to an overloaded and distended  
stomach4     ,much discretion is needed 
in fixing on the kind and quantity of   
food   to be given4 ,something will     
depend on the character of the disease  
under which the patient is sinking2 and 
something on the length of   time he is 
likely to survive4 ,if the act of dying 
is likely to be   protracted1 as it     
often is in cancer and some cases of    
consumption1   where death is brought   
about by slowly progressive exhaustion1 
the   food should be supporting and in  
somewhat larger quantity4 ,i have   long
 doubted whether strong beef tea and    
meat extracts are as a rule   of much   
use1 or are appropriate when the act of 
dying has really   commenced4 ,milk1    
cream1 beaten eggs1 and the farinacea   
are far better4   ,they are1 too1 the   
best vehicles for wine and spirits2 and 
they have   less tendency than soups to 

become offensive in the stomach4        
,alcohol in its fermented or distilled  
forms is of special use in   the        
treatment of the dying4 ,owing to its   
high diffusive power it   passes readily
 into the blood4 ,it stimulates the     
failing heart1 and   thus promotes the  
circulation through the lungs1 which is 
one of   its most valuable properties in
 the dying4 ,it may perhaps increase    
the secretion of the gastric juice2 it  
more probably stimulates   the          
peristaltic movements of the stomach1   
and by so much1 aids the   digestive    
process1 and supports the patient in the
 best and most   natural manner4        
,stimulants and nutriment should as a   
rule be given   together for they       
mutually influence each other4     ,the 
quantity of wine or spirit which is     
needed varies exceedingly1   and no     
definite rule can be laid down on this  
point4 ,they should be   given in small 
quantities at a time and repeated at    
short intervals   before the effects    

upon the heart and pulse of the previous
 dose have   subsided4     ,of wines1   
sherry is perhaps the most useful4      
,port1 if preferred   by the patient1   
may be substituted1 but ,i have not     
found it1 as a   rule1 to agree as well 
as sherry4 ,madeira from its slight     
acidity is   specially agreeable to the 
palate1 and is besides the most         
sustaining   and cordial of wines4 ,but 
tokay is often more acceptable than any 
other wine1 especially to those sinking 
from exhausting diseases1 as            
hemorrhage1 profuse suppuration1 and the
 like4 ,it is best given with   cream4  
,the stimulus of these wines is longer  
maintained than is that   of other forms
 of alcohol4 ,champagne is most         
refreshing and is often   eagerly taken2
 but its effects are evanescent and it  
needs repeating   at shorter intervals  
than other wines4 ,a teaspoonful of     
brandy1 or of   some liqueur may        
sometimes be advantageously added to it4
     ,sometimes brandy answers better   

than any wine1 especially if the        
stomach is irritable and there is nausea
 or vomiting4 ,as a mere   stimulant it 
is best administered with yolk of egg   
and sugar1 as   is ,sir ,henry          
,halford's celebrated mixture--the      
,mistura ,spiritus   ,vini ,gallici of  
the ,pharmacopia4 ,if brandy is used for
 its special   tranquillizing influence 
on an irritable stomach1 it may be given
   neat1 in drachm doses1 or in double  
that quantity in a little simple1   or  
in one of the arated1 waters4 ,the wish 
of the patient for any   particular form
 of stimulant is almost always a correct
 indication for   its use4     ,the dry 
and parched condition of the tongue and 
mouth so common in the   dying1 and the 
inextinguishable thirst that attends    
some forms of it1   need constant       
attention4 ,a spoonful of iced-water    
repeated frequently   will be a great   
comfort4 ,so1 too1 is a small bit of ice
 allowed to   dissolve in the mouth--or 
lemonade--or weak black tea without     

milk1   and slightly acidulated with a  
slice of lemon4     ,in the case of     
nutriment and stimulants as of mere     
diluents1 it is to   be                 
understood--supposing there is nothing  
to forbid--that so long as   the lips   
close upon them1 and an act of          
swallowing follows promptly1   they may 
be continued3 but when liquids seem     
merely to trickle down   the throat1 and
 after a time1 only to excite a faint   
effort of   swallowing1 they should no  
longer be persisted in4 ,the sensibility
   of the parts is so diminished that   
the patient is insensible to the        
stimulus of the liquid1 and we infer a  
fortiori to the dry and   parched state 
of the mouth and fauces4 ,if1 after     
rubbing the lips   gently with the      
spoon1 or with the spout of the feeding 
vessel1 no   evident and distinct act of
 swallowing follows1 it is useless1 and 
it may be cruel to persist2 the liquid  
will but clog the mouth and   fauces1   
add to the impediment to breathing1 and 

by so much1 if any   consciousness      
remains1 to the sufferings of the dying4
           99       99       99       99
       99     ,next in value to         
stimulants in the treatment of the dying
 is opium4   ,it is a tradition that    
,john ,hunter used often to exclaim1    
8,thank ,god   for opium10#eb and under 
no circumstances are we bound to be more
   thankful for it then when ministering
 at the bedside of the dying4   ,opium  
is here worth all the rest of the       
materia medica4 ,its object and   action
 must however be clearly understood4    
,opium is administered to   the dying1  
as an anodyne to relieve pain2 or as a  
cardiac and cordial   to allay that     
sinking and anguish about the stomach   
and heart1 which   is so frequent in the
 dying1 and is often worse to bear than 
pain1   however severe4 ,opium should   
rarely be administered to the dying as a
   mere hypnotic1 or with a view to     
enforce sleep4 ,to do so would be to    
risk throwing the patient into a sleep  

from which he may not awake4   ,but     
opium often induces sleep indirectly1   
and in the kindest way1 by   the relief 
of pain1#ec or sinking that had hitherto
 rendered sleep   impossible4     ,for  
the relief of pain in the dying wherever
 it may be situated1   we have our one  
trustworthy remedy in opium4 ,heberden  
writes1 8,in   impetu autem doloris1 ubi
 ubi is fuerit1 opium est unicum        
remedium40   ,if judiciously and freely 
administered it is equal to most of the 
emergencies in the way of pain1 that we 
are likely to meet with in the          
dying1#ed whereas if timidly and        
inadequately used1 the sufferer is      
deprived of the relief which it alone is
 capable of affording4     ,the value of
 opium in allaying pain1 great as that  
is1 is however   second to its value in 
relieving the feeling of exhaustion and 
sinking--of indescribable distress and  
anxiety--referred to the   stomach and  
heart1 which so often attends some part 
of the act of   dying4 ,to the practised

 eye1 this condition is evidenced1 as   
much   by the pinched features1 pallid  
complexion1 and anxious expression   of 
face1 as by any verbal complaint of the 
sufferer4 ,here the   action of opium is
 that of a cordial in the fullest sense 
of the   word4 8,of all cordials10 says 
,sydenham1 8opium is the best that has  
hitherto been discovered4 ,i had nearly 
said10 adds he1 8that it is   the only  
one40#ee 8,under the protection of an   
opiate10 writes ,dr4   ,heberden1#ef    
8the patient's strength has been kept   
up1 and even in   hopeless cases in     
which the dying person is harassed by   
unspeakable   inquietude1 he may be     
lulled into some composure1 and without 
dying   at all sooner may be enabled to 
die more easily40 ,i know of nothing    
in our attendance on the dying more     
gratifying1 than to witness the         
improvement in face1 feature1 and       
expression1 that marks the kindly       
action of opium under these             
circumstances4 ,in an hour or           

thereabouts1   after it has been taken1 
some colour returns to the face1 the    
features   lose somewhat of their       
sharpness1 a placid expression replaces 
the   look of anxiety1 and the sufferer 
passes into an easy1 gentle sleep1      
from which he awakes refreshed and      
comforted1 and helped as it would       
seem1 to die more easily1 when his time 
arrives4 ,hufeland1 writing at   the end
 of a long professional life1 did not   
hesitate to declare that   opium 8is not
 only capable of taking away the pangs  
of death1 but it   imparts even courage 
and energy for dying40#eg     ,opium    
must be administered in such doses as   
will appease suffering and   disorder1  
and in this respect we are to be        
governed solely by the   effect and     
relief afforded4 ,the dose for an adult 
should be rarely   less than a grain1   
but oftener more4 8,there exists10      
writes ,sir ,henry   ,holland1          
8distrust1 both as to the frequency and 
extent of its use not   warranted by    

facts1 and injurious in many ways to our
 success20#eh   8its use is not to be   
measured timidly by tables of doses1 but
 by   fulfilment of the purpose for     
which it is given4 ,a repetition of     
small   quantities will often fail1     
which concentrated into a single dose   
would safely effect all we require40#ei 
,the effects of opium continue for about
 eight hours1 and if its   action is to 
be maintained it should be repeated at  
intervals of   that duration or somewhat
 less4 ,the dose is to be governed      
solely by   the relief afforded4 ,its   
effects are usually limited to relief of
   the pain1 or of the sense of sinking 
for which it has been given1   producing
 no other direct effect on the system in
 general4 8,it would   seem10 says ,sir 
,henry ,holland1 8that the medicine1    
expending all its   specific power in   
quieting these disorders1 loses at the  
time every   other influence on the     
body4 ,even the sleep peculiar to opium 
appears   in such instances to be       

wanting1 or produced chiefly in effect  
of the   release from suffering40#fj    
,opium should always be given to the    
dying in its liquid forms--as the       
tincture1 or the liquid extract--or as  
morphia1 of which ,i know of no         
preparation of equal value to the       
solution of the bimeconate4     ,so long
 as the air passages are not obstructed 
by secretion1 so long   as there is     
neither lividity nor even duskiness of  
face1 opium1 if   indicated1 may be     
given in aid of the ,euthanasia2 but if 
they are   present1 it is hazardous and 
might hasten death4 ,much care1 too1    
is needed in the employment of opium1 in
 cases where the heart is   greatly     
enfeebled1 and where the conditions1    
directly or indirectly   induced by     
opiates1 especially that of sleep1 may  
be just enough   to turn the balance    
against it4 ,a contracted pupil is also 
a   contra-indication to opium2 it      
implies a state of the brain1 which     
opium is likely to increase rather than 

relieve4 ,and if food has   been        
injudiciously pressed upon the patient1 
so that the stomach is   distended with 
it1 and the epigastrium is full and     
tense1 opium given   by the mouth is    
rarely found to act kindly1 if at all4  
,if1 under such   circumstances1 the    
influence of opium is needed1 we should 
resort to   the hypodermic injection of 
morphia4     ,professor ,paradys warns  
us of the confusion of the senses and of
 the   mind that sometimes follows the  
administration of opium to the dying1   
and which to some persons is worse to   
bear than the sufferings for   which it 
has been prescribed4#fa ,but this1 in my
 experience1 has been   rare1 and will  
be seldom observed if opium is          
restricted to the cases   where1 as ,i  
have stated above1 it is specially      
called for1--namely1 in   relief of pain
 or of severe sinking4 ,when1 however1  
it does occur in   these circumstances1 
it is probably due1 either to an        
idiosyncrasy on   the part of the       

patient1 or to the inadequacy of the    
dose given1 which   has been enough to  
confuse and stupify the senses1 but not 
to control   the symptoms for which it  
was administered4 8,si timide et nimis  
parce   datum fuerit10 writes ,dr4      
,gregory1#fb 8longe alium effectum      
habebit1   et iisdem grotis haud parum  
nocebit1 quibus largius datum multum    
profuisset40           99       99      
99       99       99     ,ammonia is    
inferior as a stimulant to wine and     
brandy1 which are   more palatable and  
preferable1 while as an antispasmodic it
 is very   inferior to ether4 ,but it is
 useful where the respiration flags     
and the breathing is obstructed by      
secretion accumulating in the           
bronchial tubes1 and the complexion is  
becoming dusky and livid4 ,five   grains
 of the carbonate dissolved in camphor  
water is a good mode   of administering 
it4 ,small doses of oil of turpentine   
are sometimes   more effectual than     
ammonia4 ,a drachm of the confection of 

turpentine   rubbed up in peppermint    
water1 is perhaps the best form of      
giving it4           99       99        
99       99       99     ,next in value 
to opium in its power of alleviating the
 sufferings of   the dying is ether4 ,it
 is specially indicated in gasping or   
spasmodic   difficulty of breathing1    
whether dependent on the lungs or heart2
   and in flatulent distention of the   
stomach1 attended with unavailing       
efforts at eructation4 ,these two       
conditions are often conjoined in the   
dying1 and then the indication for ether
 is the strongest4 ,according   to my   
experience ether is most efficient when 
given in combination   with a few drops 
of sulphuric acid1 as in the acid       
infusion of roses1   or better with mint
 water and sugar1 as in the so-called   
8ether   punch40#fc ,opium or laudanum  
in somewhat smaller doses than those    
recommended above1 is often added1 with 
great advantage to ether1 when   there  
is need of a potent antispasmodic4 ,in  

the paroxysms of severe   prcordial     
anguish and dyspna that characterize    
many deaths from   organic disease of   
the heart and great vessels of the      
chest1 relief   must be sought in ether 
and opium1 or from the inhalation of the
   nitrite of amyl4           99        
99       99       99       99     ,the  
fewer the drugs and the less of medicine
 we can do with in the   treatment of   
the dying1 the better4 ,those above     
mentioned comprise   all ,i have had    
occasion for1 and if judiciously used1  
they are equal   to the emergencies we  
are called upon to meet4 ,i have no wish
 unduly   to limit the means at our     
command in aid of the ,euthanasia2 but  
when   the stage of existence           
contemplated in these pages has once    
been   reached1 we dismiss all thought  
of cure1 or of the prolongation of      
life1 and our efforts are limited to the
 relief of certain urgent   conditions1 
such as pain1 exhaustion1 dyspna1 spasm1
 and the like2   for which the remedies 

mentioned above are to the full as      
efficient1   if not really more so1 than
 any others as yet known4 ,but no       
medicine   should be given without a    
distinct--,i had almost written         
urgent--need   for it2 and the physician
 should form a clear idea of the special
   requirements of the case before him1 
and how1 and by what means   they may be
 best accomplished4 ,in very many cases 
there is no need   of medicines of any  
kind1 and stimulants and light          
nourishment   cautiously administered1  
meet every requirement4 ,but often1 and 
in   almost all cases1 at a certain     
period of their course1 the less even   
of these that is given the better4      
8,medici plus interdum quiete1 quam     
movendo et agendo proficiunt10 writes   
,livy1 and there are few dying   beds1  
where1 just before the last1 this       
precept does not find its   fitting     
application4 8,all that the dying       
person1 then1 requires is to   be left  
alone1 and allowed to die in peace40#fd 

8,disturb him not--let him pass         
peaceably40     8,the physician10 writes
 ,dr4 ,ferriar1#fe 8will not torment his
 patient   with unavailing attempts to  
stimulate the dissolving system1 from   
the   idle vanity of prolonging the     
flutter of the pulse for a few more     
vibrations3 if he cannot alleviate his  
situation1 he will protect his   patient
 against every suffering which has not  
been attached to it by   nature40       
,as the patient himself is wholly unable
 to explain what is needful in   his    
situation1 the physician is bound to act
 for him in regulating the   economy of 
the bed-chamber4 ,the temperature and   
ventilation of the   room--the amount of
 light to be admitted--the degree of    
quiet to be   maintained in it--must be 
determined according to the             
circumstances of   each particular case4
     ,when the mode of dying is by the  
lung1 and in the way of asphyxia1 the   
admission of fresh1 cool air into the   
room seems to conduce to the   relief of

 dyspna1 and greatly to the comfort of  
the sufferer4     ,the custom of        
excluding daylight as far as may be from
 the dying   chamber1 and keeping it    
gloomy and dark1 is in every respect a  
mistake1 and is to be opposed4 ,if there
 is one thing about his   surroundings  
which more often than any other is      
complained of by the   dying1 it is of  
failing sight--of a darkness gathering  
over him2 and a   desire is expressed   
for more light4     ,talking in an      
undertone and whispering in the presence
 of the dying is   to be peremptorily   
checked4 ,what has to be said1 and the  
less that is   the better1 should be in 
a clear1 distinct1 ordinary tone1       
somewhat1   perhaps1 below the          
ordinary4#ff     ,the dying chamber is  
no place for officious interference or  
obtrusive   curiosity4     ,the fewer   
that are admitted to it the better--the 
nurse1 the minister   of religion1 the  
medical attendant1 and the immediate    
members of the   family1 comprise those 

whose duty and feelings entitle them to 
be   present4     8,while the senses    
remain perfect1 the patient ought to    
direct his own   conduct1 both in his   
devotional exercises1 and in the last   
interchange   of affection with his     
friends40#fg ,he will be wise if he does
 so   under the experienced guidance of 
his religious adviser4 8,the powers   of
 the mind1 after being forcibly exerted 
on these objects1 commonly   sink into  
complete debility1 and respiration      
becoming weaker every   moment1 the     
patient is rendered apparently          
insensible to everything   around him4  
,but the circumstances of the disease   
occasion much variety   in this         
progress40#fh     ,even when persons    
appear insensible1 it is certain1 as ,i 
have before   remarked1 that frequently 
they are cognisant of what is passing   
about   them4 8,i have known them       
requested10 says ,dr4 ,elliotson1 8to   
give a   sign that they were still alive
 by moving a finger1 or by interrupting 

their breath when to move a finger was  
impossible3 and they have   done so1    
although believed by many to have been  
long senseless40#fi   ,in many cases    
there is a sort of lucid interval       
immediately before   dissolution4 ,this 
may be perceived by the looks and       
gestures where the   patient is         
incapable of speaking4     ,when things 
come to the last and the act of         
dissolution is imminent1   all noise and
 bustle about the dying person should be
 prohibited1 and   unless the patient   
should place himself in a posture       
evidently uneasy   he should be left    
undisturbed4#gj ,the dying are often    
impatient of   any kind of covering4#ga 
,they throw off the bedclothes and lie  
with   the chest bare1 the arms abroad1 
and the neck1 arms1 and legs as much    
exposed as possible3--,ubi supinus ger  
jacet1 porrectis manibus et   cruribus1 
writes ,celsus--ubi brachia et crura    
nudat et inqualiter   dispergit4 8,these
 actions10 writes ,dr4 ,symonds1#gb 8we 

believe to be   prompted by instinct1 in
 order that neither covering nor even   
contact   with the rest of the body may 
prevent the operation of the air on the 
skin4 ,there are actions and re-actions 
between the air and the blood   in the  
skin similar to those which occur in the
 lungs1 and these are   in aid of them40
 ,such automatic actions ought not to be
 interfered   with1 unless the patient  
has got into a position evidently       
distressing   to himself1 or except so  
far as decency requires when there is   
any   approach to unseemly exposure4    
,exclamations of grief1 and the crowding
 of the family round the bed1   only    
serve to harass the dying man1 writes   
,ferriar1 who adds1 8,the   common      
practice of plying him with liquors of  
different kinds1 and of   forcing them  
into his mouth when he cannot swallow1  
should be totally   abstained from40    
,but to this error ,i have already      
referred4     ,it was a custom in the   
,middle ,ages to strip the dying1 drag  

them from   their beds1 and lay them on 
ashes or on mattresses of straw or hair 
upon the floor4 ,it was then wholly or  
in part a penitential act1 and   the    
influence of this custom has1 perhaps1  
not yet wholly ceased4   8,it is10 says 
,dr4 ,ferriar1#gc 8a prevalent opinion  
among nurses and   servants that a      
person whose death is lingering cannot  
quit life   while he remains on a common
 bed1 and that it is necessary to drag  
the bed away and place him on the       
mattress4 ,this piece of cruelty   is   
often practised when the attendants are 
left to themselves4 ,a   still more     
hazardous practice has been very        
prevalent in ,france and   ,germany1 and
 ,i am afraid is not unknown in this    
country4 ,when the   patient is supposed
 by the nurses to be nearly in a dying  
state1 they   withdraw the pillows and  
bolster from beneath the head1 sometimes
 with   such violence as to throw the   
head back and to add greatly to the     
difficulty of respiration4 ,as the      

avowed motive for this barbarity   is a 
desire to put the patient out of        
pain--that is1 to put him to   death--it
 is incumbent on his friends to preserve
 him from the hands   of those          
executioners4 ,perhaps a more deplorable
 condition can   scarcely be conceived  
than that of being transferred from the 
soothing   care of relations and        
friends1 to the officious folly or      
rugged   indifference of servants40 ,one
 would hope that such cruelty is a thing
   of the past4 ,my own experience forty
 years since as a dispensary   physician
 in the eastern parts of the metropolis1
 led me to conclude   that it was not   
then and there wholly unknown or        
unpractised4 ,what   it may be in remote
 rural districts1 where the class of    
old1 ignorant   and prejudiced nurses   
still exist1 ,i have no means of        
knowing4 8,this   is a state of         
suffering10 adds ,dr4 ,ferriar1 8to     
which we are all   exposed1 and if it   
were unavoidable1 ,i should be far from 

desiring   to unveil so afflicting a    
prospect4 ,but the means of prevention  
are   so easy1 that ,i cannot forbear to
 solicit the public attention to        
them40#gd     ,in the intelligent       
trained nurses of the present day1 we   
have the   best security against such   
barbarity2 and when they are absent1 in 
the   presence in the dying chamber1 of 
the relations or nearest friends   until
 all is over4     ,in cases of sudden   
death from disease of the heart1 there  
is neither   occasion nor time for      
medical treatment of any sort4 ,death is
   instantaneous and without warning4   
,where death beginning at the heart     
takes place by way of syncope1 fresh air
 and stimulants cautiously   given are  
the best resources4 ,wine or brandy1    
with egg or other   light nutriment1 are
 appropriate4 ,when death is taking     
place in the   slower way of exhaustion1
 a like treatment is to be pursued4 ,in 
the   earlier stage1 small quantities of
 soup1 or beef tea may be given1 but    

when death is near they are best        
omitted4 ,it is in these cases that     
madeira and tokay answer so well4 ,in   
all cases of dying by failure of   the  
heart's action1 the posture of the      
patient should be carefully             
adjusted--the head should be low rather 
than raised1 and it and   the shoulders 
supported on firm pillows4 ,any approach
 to the erect   or sitting posture is as
 a rule to be avoided4 ,its tendency is 
to   occasion fainting and death4       
,in death from the lungs or by asphyxia 
the struggle is often   protracted1 and 
accompanied by all those marks of       
suffering which the   imagination       
associates with the closing scene of    
life4 ,doubtless in   the earlier stages
 of it1 there is real suffering1 but    
happily this is   rarely of long        
duration1 for the circulation of venous 
blood ensues1   and deadens sensibility 
and pain4 ,the respirations in this mode
 of   death become laborious and        
heaving1 the expression of countenance  

distressed and anxious4 ,but soon the   
face becomes tumid and dusky1   the lips
 livid1 and with the circulation of     
undecarbonized blood1   which these     
symptoms imply1 the anxious expression  
of face subsides1   and there ensues a  
slowly increasing benumbing of          
sensation1 and a   corresponding        
diminution of suffering4 ,the breathing 
then becomes   irregular and laborious1 
and the heavings of the chest           
convulsive2   but these movements are   
automatic1 and independent alike of     
sensation   and of the will4 ,they soon 
pass into coma1 stertor1 rattle in the  
windpipe1 and death4 ,stertorous        
breathing is in great measure due to    
affection of the brain or medulla1      
either primary or secondary4 ,the       
latter is the condition we are here     
contemplating4 ,stertor seems to   be   
due to a falling back of the base of the
 tongue into the pharynx1   and to the  
obstruction to respiration thence       
induced2 and is increased   by the prone

 position on the back1 into which such  
patients naturally   fall4 ,it may be   
relieved by placing the person on one   
side1 and   supporting him in that      
position by well-arranged pillows4 ,the 
tongue   then drops to the side of the  
pharynx and mouth1 and leaves room   for
 the ingoing air4 ,dr4 ,bowles1 of      
,folkestone1 to whom we owe the         
knowledge of these facts1 warns us1 that
 care should be taken to keep   the neck
 rather straight1 as1 if the chin be    
brought too near the   sternum1 the     
thyroid cartilage presses upwards and   
backwards1 and   again pushes the base  
of the tongue1 toward the back of the   
pharynx4   ,nothing can be done1 indeed 
nothing is needed1 but regulation of the
   posture1 when coma is established4   
,the head is to be supported on a   firm
 pillow1 or bolster1 and slightly       
raised1 but not so much as to   increase
 the tendency to slide downwards in the 
bed4 ,whatever position   of the body is
 found to lessen the stertor1 and ease  

the breathing   should be maintained4   
,in the earlier stages of the process   
above described--in the condition       
which precedes and passes into coma--a  
carefully adjusted posture of   the     
patient1 in which he is propped up at an
 angle of not less than   forty-five    
degrees1 and often at one of much more1 
and due support   is given to the trunk 
of the body by pillows--will do more    
than   anything else in relief of       
embarrassed and laboured breathing4     
8,the   object is to support with the   
pillows1 the back below the breathing   
apparatus1 to allow the shoulders room  
to fall back1 and to support   the head1
 without throwing it forward40#ge ,the  
suffering of dying   patients1 says     
,miss ,nightingale1 is immensely        
increased by neglect   of these points4 
,if secretions have accumulated in the  
air passages1   ammonia or turpentine   
may be administered4 ,should the        
breathing be   gasping and spasmodic1   
ether1 with or without opium1 should be 

tried4   ,when duskiness and lividity of
 the face have come on1 we can do but   
little--when deep coma and stertorous   
breathing1 nothing--but adjust   the    
posture of the patient to the more      
pressing requirements of the   case4    
,when the heart or great vessels of the 
chest are the seat of the   disease1 and
 the circulation through the lungs is   
becoming seriously   embarrassed by it1 
there are often paroxysms of great      
suffering4 ,the   patient is agonized by
 a sense of instant suffocation1 and    
sits in or   out of bed1 with the head  
bent forward1 resting on a table or     
other   support1 and expecting          
dissolution every moment4 ,here ether   
and opium   is our best resource2 or the
 nitrite of amyl1 the cautious          
inhalation   of which has in some       
instances given marked relief4     ,when
 death1 commencing at the brain1        
destroys life through the lung1   and in
 the way of coma1 as it usually does1   
the treatment is the same   as in the   

coma that occurs late in the series of  
events which mark   death by asphyxia4  
,when1 on the other hand1 death1        
beginning at the   brain1 destroys life 
through the heart and by way of         
exhaustion1 the   treatment is the same 
as above described for those dying      
primarily   from the heart and in the   
way of asthenia4           99       99  
99       99       99     ,when the face 
of the dying person is flushed1 the head
 hot1 and the   carotid arteries beating
 forcibly1 the head is to be raised and 
supported on firm pillows1 and ice or a 
cold spirit lotion applied to   it4     
99       99       99       99       99  
,in some delicate and highly sensitive  
persons1 a kind of struggle is          
sometimes excited when the respiration  
becomes very difficult4#gf   ,dr4       
,ferriar says he has known this effort  
proceed so far1 that the   patient a    
very few minutes before death1 has      
started out of bed1 and   stood erect   
for a moment4 ,he ascribed it to        

apprehension and alarm1   and adds3     
8,those who resign themselves quietly to
 their feelings seem   to fare best40   
,this is probably true1 but the sufferer
 needs whatever   relief art can supply2
 and ether and opium is the most likely 
to give   it4           99       99     
99       99       99     ,hiccup is     
somewhat alleviated by a sinapism to the
 epigastrium1 and   a spoonful of       
aniseed water swallowed slowly4 ,but if 
it is severe1   shaking the patient1 and
 so adding greatly to his distress1 we  
must   rely on opium given internally1  
and its application externally to the   
pit of the stomach4 ,if hiccup seems to 
be due1 as it often is1 to   an         
overloaded and distended stomach1 and   
the influence of opium is   needed1 the 
hypodermic injection of morphia is to be
 preferred4           99       99       
99       99       99     ,inquietude and
 restlessness1 especially in the        
half-conscious dying   person1 is often 
due to a distended bladder1 and is at   

once quieted by   the catheter4 ,in     
others1 it is due to the weight of the  
bedclothes1   and is relieved by        
lightening them4           99       99  
99       99       99     ,coldness of   
the feet is best met by a foot warmer2  
and not by thick1   heavy bed clothing1 
which distresses the sufferer and gives 
rise to   inquietude and restlessness4  
8,weak patients10 says ,miss            
,nightingale1   and the dying as much or
 more so than others1 8are invariably   
distressed by a great weight of         
bedclothes40 ,light ,whitney blankets   
should alone be used for coverings under
 such circumstances4 ,but ,i   am not   
sure that coldness of the extremities   
does always add to the   sufferings of  
the dying1 or needs the consideration   
usually given to   it4 ,the diminished  
circulation on which it depends is      
attended1 for   the most part1 in the   
dying by proportionate loss of          
sensibility2 and   besides it is        
especially when the feet and legs are   

cold1 sodden1 and   dank1 that we       
observe that impatience of any covering 
upon them--that   tossing about and     
exposure of them to the air--which ,i   
have before   described4           99   
99       99       99       99     ,death
 from old age--the natural termination  
of life1 and the   simplest form of     
death that can occur1 creeps on by slow 
and   almost imperceptible degrees4 ,it 
is characterised by a gradual and       
proportionate decay of all the functions
 and organs of the body1 and   as a rule
 presents no symptoms that call for     
special treatment4 ,it   is only where  
the normal course of decay is disturbed 
by supervening   disorder1 or disease of
 an important organ1 or by surrounding  
circumstances1 that suffering of any    
kind attends it4 ,good nursing1   and   
the due administration of light food and
 stimulants1 comprise all   that is     
needed4 ,the approaches to death are so 
gentle1 and the act of   dying so easy1 
that nature herself provides a perfect  

euthanasia4        ,,the ,,end4         
,,unwin ,,brothers1 ,,printers1         
,,chilworth ,,and ,,london4             
,,footnotes3     #ea ,medical ,notes and
 ,reflections4 ,third edition1 #hvo1    
,london1 #ahee1  p4 #cgi4     #eb       
,robert ,willis1 ,m4,d41 ,on ,urinary   
,diseases1 #hvo1 ,london1 #ahch1 p4     
#ajj4     #ec 8,when there is a sudden  
cessation1 or intermission1 of acute    
pain1  sleep frequently comes on        
instantaneously at every such interval  
of  ease4 ,the records of judicial      
torture furnish much striking evidence  
as  to these effects40 7,sir ,henry     
,holland's ,medical ,notes and          
,reflections1  p4 #cfi47     #ed ,i     
except hydrophobia1 tetanus1 c41 against
 which it is almost  powerless4     #ee 
8,prstantissimum remedium cardiacum     
7unicum pene dixerim7 quod in  rerum    
natura hactenus est repertum40 ,sydenham
 ,thom ,opera ,omnia1 edidit  ,g4 ,a4   
,greenhill1 ,m4,d41 #hvo1 ,london1      
#ahdd1 p4 #age4     #ef 8,vires gri     

somno recreat sunt1 atque etiam ubi     
salus ejus  prorsus desperata fuerit1 et
 angor summus cruciaverit1 opium utique 
sollicitudinem aliquantum levavit4 ,mors
 quidem neque serius1 neque  citius     
venit1 sed tamen minore cum cruciatu40  
7,heberden ,de ,ileo47     #eg          
,hufeland's remarks on opium are so     
valuable that ,i give them at  length4  
8,who would be a physician without opium
 in attendance on cancer  or dropsy of  
the chest8 ,how many sick has it not    
saved from despair8  ,for one of the    
great properties of opium is1 that it   
soothes not only  corporal pains and    
complaints1 but affords also to the mind
 a peculiar  energy1 elevation1 and     
tranquility4 ,the soothing virtue       
manifests  itself in the most splendid  
manner in relieving death in severe     
cases1  in effecting the euthanasia1    
which is a sacred duty and the highest  
triumph of the physician1 when it is not
 in his power to retain the  ties of    
life4 ,here1 it is not only capable of  

taking away the pangs of  death1 but it 
imparts even courage and energy for     
dying2 it promotes  in a physical way   
even that disposition of mind which     
elevates it  to heavenly regions4 ,a man
 who had laboured for a long time under 
complaints of the chest and vomicas     
finally approached death4 ,the most     
dreadful anguish of death with a        
constant danger of suffocation seized   
him1 he got into real despair and his   
state was an insurmountable  torment    
even for the persons around him4 ,he now
 took half a grain of  opium every hour4
 ,after three hours he became quiet1 and
 after he had  taken two grains he fell 
asleep1 slept quietly for several hours1
 awoke  quite cheerful1 free from pain  
and anxiety1 and at the same time so    
much strengthened and appeased in his   
mind1 that he bade farewell with  the   
greatest composure and satisfaction to  
his relatives1 and after  he had given  
them his blessing and many a good       
admonition fell again  asleep and passed

 away while sleeping40 7,the ,three     
,cardinal ,means of  the ,art of        
,healing1 p4 #df47    ,somewhat to the  
same purport writes ,de ,quincey4       
8,simultaneously with  the conflict the 
pain of conflict has departed1 and      
thenceforward  the gentle process of    
collapsing life1 no longer fretted by   
counter-movements slips away with holy  
peace into the noiseless deeps  of the  
,infinite40 7,confessions of an ,english
 ,opium-,eater1 p4 #adi47     #eh ,ut   
supra1 p4 #eaf4     #ei ,holland1 ut    
supra1 p4 #eah4 ,to the same effect     
writes ,dr4 ,james  ,gregory of this    
remedy1 8,neque dubium est1 utcunque    
periculosus  videatur usus talis        
medicamenti vix non venenati2 gros plus 
fere  incommodi et damni percepisse a   
nimis parva1 quam a nimia ejus          
quantitate4 ,medici igitur est1         
medicamentum adeo validum et spe        
perniciosum caute et prudenter adhibere1
 et in illis tantum morbis ad  id       
confugere1 qui aliquid istiusmodi plane 

requirunt2 ubi vero talis  necessitas   
urget1 oportet remedium libere et cum   
fiducia prscribere2  tunc enim non      
sperare modo potest1 sed fere polliceri1
 se effectum  illum salutarem1 quem     
cupit1 per suum medicamentum esse       
prstiturum4  ,quod si timide et nimis   
parce datum fuerit1 longe alium effectum
  habebit1 et iisdem grotis haud parum  
nocebit1 quibus largius datum  multum   
profuisset40 7,conspectus ,medicin      
,theoretic1  ,,mccxxii47     #fj ,ut    
supra1 p4 #eah4     #fa 8,audivi plus   
semel gros temporarium a narcoticis     
levamen enixe  deprecantes1 quod sensuum
 obscuratione nimis care querebantur    
emi40 7p4  #ga47     #fb 8,conspectus   
,medicin ,theoretic10  ,,mccxxii4       
#fc           ,aq4 ,menth ,viridis1 f4  
v ss4        ,sacchari1  ss4            
,acid4 ,sulphurici diluti  ,,xl4        
,sp4 theris comp4 f4  ij4      ,misce ft
 ,mistura4 ,pars quarta pro dose4       
#fd ,elliotson1 ,human ,physiology1 p4  
#ajdc4     #fe ,ut supra1 p4 #aic4      

#ff ,miss ,nightingale's observations on
 whispered conversation in the  room1 or
 just outside the door1 at p4 #bf of her
 8,notes on ,nursing10  have great value
 and a wide application4 ,on these      
points in the  management of the dying  
chamber ,professor ,paradys has the     
following3  8,sed prterea adhiberi hoc  
loco moderat sensuum externorum         
impulsiones  utiliter possunt1 qu       
vividiores phantasmatum impressiones    
obscurent3  vitari itaque nimi tenebr et
 silentia nimis alta debent1 concedi    
contra modica lux1 permitti not amicorum
 voces1 immo excitari debent  lenes1    
placidi1 animum blande demulcentes      
affectus40 7p4 #gd47     #fg ,ferriar1  
p4 #aic4     #fh ,ibid41 p4 #aid4       
#fi ,human ,physiology1 p4 #ajdc4       
#gj ,ferriar1 p4 #bjc4     #ga          
8,nihil adeo posses quoiquam leve       
tenueque membris ,vortere in            
utilitatem40 7,lucretius vi4 #aafi47    
8,nor would once endure ,the lightest   
vest thrown loosely o'er the  limbs40   

7,mason ,good1 p4 #eie47     #gb        
8,cyclopdia of ,anatomy and             
,physiology10 vol4 i4 p4 #hjb4     #gc  
,p4 #bjj4     #gd ,p4 #bjc4     #ge     
,miss ,nightingale's ,notes on ,nursing1
 p4 #dg4     #gf ,ferriar1 ut supra1 p4 
#aif4